This is a question that the Compliance Department is often asked. The Yale Medical Group primarily utilizes the guidelines established by the Center for Medicare and Medicaid Services (CMS) as our documentation and billing standard. CMS has a long standing policy that they do not pay for visits with family when the patient is not present.
"In the office and other outpatient setting, counseling and /or coordination of care must be provided in the presence of the patient."
Face-to-face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face to face physician / patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends upon the physician service provided.
If a patient is withdrawn and uncommunicative due to a mental disorder or is comatose, the time a physician spends with family members or close associates to secure background information regarding the patient may be billable as an E&M. If the patient has a mental, psychoneurotic or personality disorder and is not an inpatient of a hospital, then Medicare will apply a special limitation allowance on the payment.
Family counseling services may also be covered by Medicare if the primary purpose of such counseling is the treatment of the patient’s condition. The two scenarios provided by Medicare are:
- where there is a need to observe the patient’s interaction with family members and/or
- where there is a need to assess the capability of and assist the family members in aiding in the management of the patient.
In both examples, the patient would be present.
In the inpatient setting, if the patient is in critical condition and unable or clinically incompetent to participate in discussions, time spent on the floor or unit with family members or surrogate decision makers may be reported as critical care for the following activities:
- obtaining a medical history,
- reviewing the patient’s condition or prognosis,
- discussing treatment or limitation(s) of treatment
The time for these activities may be counted if the focus of the conversation bears directly on the medical decision making.
Discussions with family members when patients are not present will not, in most cases, be covered by other payers. For many insurers, the patient must be present when family members want an update from the physician in order to be considered as a time factor and reimbursable by insurance carriers.
In the pediatric world, the American Academy of Pediatrics (AAP) has stated that it is common for parents to come in and discuss a child’s condition or problem without the child being present. The AAP recommends that the physician can report the E&M service using time as a key factor even if the child is not present. However, a poll done by the YMG Patient Financial Services (PFS) area indicates that the private payers may have their own rules surrounding visits in which the patient is not present. For example, Aetna and HealthNet cover the services whereas Anthem BCBS and CIGNA do not. We recommend that departments check with Sally Chesney in PFS before billing for a service to a private payer in which the patient is not present.